Concept:Paraspinal Corrective Actions

Paraspinal Corrective Actions is the canonical programme for reducing and eliminating the structural and behavioural perpetuating factors that maintain trigger points (TrPs) in the thoracolumbar paraspinal muscles. This page is cross-referenced by Muscle:Thoracolumbar_Paraspinal/Superficial, Muscle:Thoracolumbar_Paraspinal/Deep, Muscle:Serratus_Posterior, Muscle:Quadratus_Lumborum, and other torso muscle pages. The content follows Chapter 48, Section 14 of Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1.

The most important principle in this programme is: correct structural inadequacies first. Active TrPs can spontaneously revert to latent TrPs in a few days or weeks once the perpetuating mechanical load is removed. Conversely, failure to correct structural asymmetry converts an acute TrP problem into a chronic one, regardless of how well the TrPs themselves are treated.

See also Concept:Perpetuating_Factors for the complete range of systemic and nutritional perpetuating factors.

Contents

• Structural Correction
  • Limb Length Inequality
  • Small Hemipelvis
• Chair and Seating Design
• Lifting Mechanics
• Sit-to-Stand and Stand-to-Sit Technique
• Stair Climbing
• Sleep Posture
• Self-Treatment: TrP Pressure Release
• Exercises
  • In-Bathtub Stretch
  • Low-Back Stretching Exercise
  • Abdominal Strengthening
• References

Structural Correction

Structural asymmetry imposes persistent muscle strain that perpetuates TrPs in the paraspinal and associated musculature. Correcting structural inadequacies is the single most important step in long-term management.

Limb Length Inequality

Clinical significance:

• A difference of up to 1.3 cm (½ in) in leg length alone does not activate TrPs, but is a powerful perpetuating factor that converts an acute TrP problem into a chronic one
• A difference as small as 0.3 cm (⅛ in) is often clinically significant in a short person and requires correction
• A difference of 0.5 cm (3/16 in) is often a significant source of muscle strain

Shoulder-girdle rules:

• Discrepancy <1.3 cm: the shoulder sags on the side of the longer leg
• Discrepancy ≥1.3 cm: the shoulder is lower on the shorter side
• The patient often stands on the shorter leg with the longer leg in front or to the side

Functional determination of leg length difference — standing:

1. Stand the patient with feet together or ≤7.6 cm (3 in) apart; observe from behind
2. Assess the following in order:
   1. Asymmetry of the body silhouette between the ribs and the pelvis
   2. Lateral tilt of the lumbar spine as it leaves the sacrum
   3. Ensuing lateral scoliosis
   4. Tilted shoulder-girdle axis — use scapular bulge symmetry (more reliable than shoulder line, which trapezius involvement distorts)
   5. Low posterior superior iliac spine — by palpation or by observing one low dimple
   6. Low iliac crest on one side — by palpation
3. Place a sufficient lift (pages of a pad or magazine) under the heel of the low-pelvis side — this should level the pelvis and straighten the spine and correct all other asymmetry indicators
4. Confirmatory test: Transfer the lift to the opposite heel for a moment — the patient feels uncomfortable and all asymmetry indicators worsen; this confirms which leg is short

Correction:

• Temporary: insert the correct thickness of firm felt inside the heel of the shoe on the short side
• Permanent: build up the outside of the shoe heel on the short side (if low heel); cut down the heel on the long side (if high heel)
• For corrections of ≥1.3 cm (½ in): divide the difference — remove half from the long side and add half to the short side
• The correction must be worn whenever the patient is on their feet, including bedroom slippers
• The patient should avoid walking or jogging on slanted ground or a slanted beach

Small Hemipelvis

The vertical dimension of the pelvis is usually smaller on the side of the shorter leg. This tilts the pelvis when sitting, with the same musculoskeletal effects as leg length inequality when standing.

Assessment — sitting:

1. Patient sits on a flat level wood surface (not padded)
2. Estimate the degree of pelvic tilt visually
3. Correct by placing pages or paper under the ischial tuberosity on the shorter side until the pelvis is level

Important:

• A hard surface requires less correction than a padded seat — a soft cushioned surface allows the body to tilt to the short side, shifting weight and increasing pelvic tilt; a thicker lift is therefore required on soft seating
• The patient will learn to be discriminating about the size of the "butt lift" needed for different chair seats (domed vs. scooped)
• A pelvic tilt can also be caused by: sitting on a wallet in a back pocket ("back-pocket sciatica"), sitting regularly in a tilted office chair, or sitting on a bench or stool with one end lower than the other
• The patient often compensates for a small hemipelvis by crossing one knee over the other to cantilever up the low side

Chair and Seating Design

The chair, not the muscles, should do the work of maintaining correct posture.

Backrest:

• Must provide enough lumbar support to maintain the normal lumbar lordotic curve when the muscles relax — simply reclining the backrest does not affect lumbar lordosis
• If the seat has a straight back with no forward curvature at waist level, supply lumbar support with a small pillow or roll of folded bath towel at belt level; adjust up or down for comfort
• Upper edge of the backrest should reach high enough to cover and support at least the inferior angles of the scapulae
• Backward inclination of the chair back reduces paraspinal muscle activity more effectively than contouring for lumbar or thoracic support — but only a lumbar support, not backrest inclination, significantly influences lumbar lordosis
• Optimal for typing: backrest with a backward slope, seat slightly hollowed out, no casters, firm upholstery

Seat height:

• Low enough so feet rest flat on the floor without compression of the thigh by the front edge — a footrest may be used to avoid underthigh compression

Keyboard:

• Under-surface of keyboard support should fit just above the operator's knees, keeping the keyboard close to lap-level
• Short armrests can be helpful if at the correct height for that person's body structure and work setup

Prolonged sitting:

• Paraspinal muscles should be stretched regularly by changing position
• Sustained elimination of lumbar lordosis may be helpful briefly as a postural variation but causes muscle strain if maintained for a prolonged period (e.g. when driving)

Lifting Mechanics

Safe lifting (Fig. 48.11 in T&S):

• Hold the object close to the body with the pelvis tucked in — centre of gravity falls through the pelvis, close to the hip joints
• Bend the knees and keep the back upright — transfer load from the paraspinal muscles to the hip and knee extensors
• Broaden the base of support in both anteroposterior and lateral dimensions
• Contract the abdominal muscles to increase intra-abdominal pressure — this relieves compressive forces on the lumbar intervertebral discs; the patient should avoid holding their breath

Most hazardous movement: A twisting turn while lifting or pulling. Strategies:

• Rotate the entire body and face the load squarely so force is exerted in the body's midline
• Alternatively: lift the load while facing it, then pivot with the feet to redirect the load — do not combine flexion and trunk rotation

The 90°-forward-bent standing position puts maximum strain on the lumbosacral joints — avoid

Sit-to-Stand and Stand-to-Sit Technique

This technique avoids the usual "bent-over-the-sink" posture when getting into and out of a chair.

Sit-to-stand:

1. Move the hips forward to the front of the chair seat
2. Turn the body and hips somewhat to the side
3. Place one foot beneath the front edge of the chair
4. Hold the torso erect
5. Straighten the knees and hips to lift the body — load transfers to the hip and thigh extensors, not the paraspinal muscles

Stand-to-sit (reverse):

1. Turn to the side and place one foot under the front edge of the chair
2. Keep the torso erect
3. Aim the buttocks at the front edge of the seat (not the rear)
4. Lower the body by bending knees and hips
5. Slide backward on the seat to meet the backrest

Stair Climbing

A patient with myofascial back pain tends to lean forward on stairs, which flexes the spine and loads the paraspinal muscles.

Modified technique:

• Turn the entire body to face approximately 45° toward one side
• It may be slower climbing, but this position automatically straightens posture, lightens the paraspinal load, and may allow ascending and descending without pain

Sleep Posture

• A bed that sags in the middle like a hammock aggravates tension in the back muscles — remedy by placing a plywood board (nearly as large as the mattress) between the mattress and the bed spring; alternatively, use lengthwise boards 1.3 cm thick and 15–20 cm wide, cut three-quarters of the mattress length; these can also be transported for use when travelling
• When sleeping on the side, place a pillow under the uppermost knee — this prevents the rotary torsion of the lumbar spine that occurs when the knee drops forward onto the bed

Self-Treatment: TrP Pressure Release

The patient can apply TrP pressure release to superficial back muscles by:

1. Lying supine on a tennis ball placed directly on the floor, or on a bed with a large thin book placed under the ball to reduce depth of pressure if needed
2. Moving around until the ball presses directly on the sensitive TrP
3. Using controlled body weight to apply gradually increasing pressure for one minute or more until the spot loses its deep tenderness
4. Following with moist heat and full range of motion

This technique is especially useful where back muscles overlie the ribs — iliocostalis thoracis, longissimus thoracis, and the serratus posterior muscles.

An iced tennis ball may be used as a variation.

Exercises

In-Bathtub Stretch

Indicated for loss of range of motion in the long back muscles. Should be performed in comfortably warm water (unless medical contraindication to the cardiovascular load of the heat).

1. Sit in the bathtub with warm water covering the lower limbs and lumbosacral area
2. Lean forward with knees straight; let the head hang forward
3. Walk the fingers down the shins until a pull is felt on the paraspinal muscles, then a little further to slight discomfort
4. Hold this stretch for several seconds until tautness slackens
5. Lean back, relax, and breathe deeply with abdominal respiration
6. Lean forward again to take the next step of the fingers, taking up the slack in the slightly longer paraspinal muscles
7. Repeat until full forward flexion is achieved

This step-wise passive stretch recaptures the lost range of motion of the long back muscles. The hamstrings are simultaneously passively stretched as the pelvis rotates.

Caution: If iliopsoas TrPs are also present, the forward flexion effort in this seated position contracts the iliopsoas in a shortened position and can activate latent TrPs. Inactivate iliopsoas TrPs first (see Volume 2, Chapter 5) and teach the patient to stretch the iliopsoas in case the bathtub stretch initiates a reactive cramp.

Patients who cannot get out of a bathtub due to a muscular problem should roll over on hands and knees and crawl over the side.

Dry-land version: A similar daily stretch in long-sitting on a flat surface can be very helpful if a bathtub is not available.

Low-Back Stretching Exercise

Performed supine.

Phase 1 (unilateral):

1. Draw one knee to the chest with the hands clasped around the thigh behind the knee (not the knee itself — avoid forced knee flexion)
2. This stretches the hip and low back extensors
3. Return that limb to the straight-leg starting position
4. Repeat on the other side

Phase 2 (bilateral):

1. Pull both thighs together tightly onto the chest — grasping the thighs, not the knees
2. Postisometric relaxation (PIR) can be incorporated: press the buttocks downward against the bed (contracting lumbar extensors), then relax and pull the thighs up toward the chest

The Low-back Stretch can also be performed in the supine position with hips and knees flexed and held by the hands. The patient presses the buttocks downward against the bed (contracting the lumbar extensors as the PIR contraction), then relaxes and pulls the thighs up toward the chest.

Abdominal Strengthening

Strong abdominal muscles can provide 30–50% additional weight-carrying support to the thoracolumbar spine.

• Pelvic Tilt Exercise: Stretches the paraspinal muscles while strengthening the abdominals (see Chapter 49, Fig. 49.12 in T&S)
• Sit-back, Abdominal-curl, and Sit-up Exercises: The sit-back phase should be performed slowly, not rapidly
• Graded active strengthening exercises for the abdominal muscles are an essential component of the corrective programme for chronic paraspinal TrP pain

Acute management: Acutely and severely involved back muscles may be partially relieved of stress without incapacitating most patients by temporary application of a corset or brace for low back support.

References

• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 48, Section 14.